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Errors are a lot more common than you might think. Here's how to weed out mistakes — and keep costs down.
And you thought examination gowns were scary! Consider this: Odds are, there's a mistake in that medical bill you just opened. According to a NerdWallet analysis of 2013 hospital audits by Medicare, 49% of bills contained errors, and some medical centers messed up on more than 80% of claims to Medicare. Those flubs matter to consumers more than ever, because greater health insurance cost-sharing and higher deductibles mean that a mistake can take a chomp out of your wallet. What's more, billing errors can be tough to spot and tougher to fix. Disputes can drag on, and if you don't take the right steps, your account could be put into collections. Ensure a clean bill of health with these steps.
Don't pay your doctor's bill until you receive an explanation of benefits (EOB) form from your insurer. Both statements tell you the amount being charged for your procedures, the amount your insurer is paying and what you owe. The totals should match — and if they don't, it's time to do some digging. (Keep in mind: Sometimes the doctor or hospital will send an invoice before receiving the full insurance payment, so the bill is for more than you actually owe. Wait until your insurance statement comes to find out what you're responsible for.)
Get an Itemized List
Some bills might list only a total amount owed, even if you underwent more than one procedure. If charges are lumped together in broad categories — "lab tests," say — call the billing department of your provider or hospital to request an itemized bill so you can see every single service for which you're being asked to pay. That makes it easier to spot errors.
Check the CPT Codes
Doctors use current procedural terminology (CPT) codes to categorize treatments and procedures. You can find those numerical codes on your EOB; google the digits to find out what they stand for.
Are There Obvious Errors?
A misspelled name, incorrect insurance policy number, the wrong procedure code — any of these things can lead to your claim being denied. Also, check for "phantom" services that weren't performed (such as tests that ended up being canceled) and duplicate charges (being billed twice for a single procedure). If you spot an error, ask your doctor to resubmit the bill.
Was Your Co-pay Applied?
If you paid at the MD's office, check to see if that amount was deducted from the bill.
Were You "Balance Billed"?
An in-network doctor's agreement with the insurance company usually requires that she accept the insurer's check — along with your co-pay or coinsurance — as payment in full, but some doctors might try to bill you for the rest. (Say the doctor billed $600 for a procedure but the insurer paid only $250. By law, the doctor can't charge you for the other $350.) Your insurance statement will confirm what your responsibility is; give a copy of that to your doctor.
Are There Unbundled Fees?
This means being billed item by item for things that should have been grouped together as part of a lower-priced package. Take, for example, the fee for delivering a baby: lab tests, IVs, the delivery itself and postnatal care are charges that should be bundled. Scan your bill for words such as kit and tray (each of these terms covers charges for multiple items).
Were You Up-coded?
If a doctor removes a splinter from your foot and bills the insurance company for surgery, your share might amount to hundreds of dollars. If charges seem unreasonable, google the CPT code. If the description of the procedure doesn't jibe with what you had done, call your provider and your insurer and ask for a correction.
Does the Timing Seem Off?
If you stayed in the hospital overnight, double-check the room-and-board charges. Although many plans don't allow hospitals to bill you for the day you were discharged, some hospitals do. And look for the time you were admitted: If you went to the ER at, say, 10 p.m. but weren't admitted to the hospital until after midnight, you shouldn't be billed for the previous day.
Go Right to the Source
Address questionable fees with your provider's billing department and your insurer, asking them to double-check the details. Write down the name of the person you spoke to and what you were told. If you're unable to resolve it with your provider, dial things up a notch: Put your concerns in writing and send them to your insurance company; the firm can work with you to file an appeal to dispute the charge. Send a copy of the dispute or appeal letter, along with any documentation you have, to your state's attorney general or the insurance commissioner. (Google "medical billing problem" and the name of your state — that should lead you to the right place.)
Typically you don't have to pay disputed charges until the investigation is complete, but do pay the rest of the bill — that would show that you're not just blowing it off. (You don't want your provider to turn your debt over to a collection agency — which would slam your credit score.) Send a letter with the check, letting your provider know that your insurer is looking into things. Likewise, alert the credit bureaus to the ongoing dispute by sending a letter explaining the details of your claim. Every four weeks, update both parties on the status of your claim, and check your credit reports to make sure that the disputed bill doesn't end up on the report as an unpaid account.
Sources: Kevin Flynn, president of HealthCare Advocates in Philadelphia; Pat Palmer, CEO of Medical Billing Advocates of America in Roanoke, Virginia; Stephen T. Parente, professor at the University of Minnesota Carlson School of Management; Mark Rukavina, principal at Community Health Advisors in Boston; Erin Singleton, chief of mission delivery at the Patient Advocate Foundation in Hampton, Virginia.
The content of these articles is provided by Time, Inc. and is for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Mercer is not responsible for the content. Always confer with your physician or other qualified health provider about any questions you may have regarding a medical condition or a change in lifestyle that might have an impact on your health, such as beginning a new exercise or nutrition regimen. Do not evaluate or disregard any professional advice or delay seeking such advice based on anything you have read in this article. Mercer does not recommend or endorse any specific tests, physicians, products, procedures, theories, or treatments that may be mentioned in this article.Adapted from the September 2015 issue of All You. © 2016 Time Inc. All rights reserved.
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After beginning your research, take some time to think it over. Talk with friends who have gone through or are going through the same decision-making process. Carefully consider your current health care needs and what your future needs might be. Your upfront investment of time and effort will definitely pay off!
This content was created for Mercer by The Foundry at Time Inc., April 2016.